Quebec medical system tries to put a price on death
Province, doctors to negotiate fees for euthanasia ‘ proceedings’
Quebec and its doctors are grappling with one of the most delicate discussions in the realm of assisted dying: Can you put a price on death?
They are expected to begin discussing fees for “medical aid in dying” as the province prepares to enact its historic right- to- die legislation in December.
A health ministry spokeswoman said doctors would be remunerated for euthanasia “proceedings” under existing billing agreements. While no separate fee code has been negotiated, “Discussions are to be expected with the medical federations to assess the appropriateness of adapting existing codes,” Noemie Vanheuverzwijn said.
Any fee schedule could become a model for all of Canada in February, when assisted dying is set to become legal across the nation.
Quebec’s medical aid in dying act is based on the Netherlands model. It will allow doctors to administer lethal injections to mentally fit patients suffering an incurable illness and in constant and unbearable physical or psychological pain. The patient must be in an advanced state of irreversible decline and be at the end of life.
Under new guidelines for doctors from the College des Medecins du Quebec, the injections are to be given in a series of three shots spaced about five minutes apart — one drug to relieve anxiety, another to induce a deep coma and a third drug to paralyze the breathing muscles to stop breathing and the heart.
In the Netherlands, doctors are paid about 250 euros for the act of “applying euthanasia,” said Dr. Rob Jonquiere, an architect of the Netherlands euthanasia law and communications director for the World Federation of Right to Die Societies.
In addition, doctors who act as consultants to confirm a request for euthanasia are paid 376 euros for their second opinion.
Under the Netherlands protocol, “you give an injection with a barbiturate, which is a heavy sleeping drug, and you cause a really deep coma,” Jonquiere said.
“Then you give a muscle relaxant — a snake poison- like medication that is also used in anesthesia.”
Once in a deep coma, “the patient doesn’t notice what is happening anymore. Their breathing will stop and the patient will die within a couple of minutes.”
In the Netherlands, 2.8 per cent of all deaths are by euthanasia, and 0.1 per cent by assisted suicide, where the doctor writes a prescription for a fatal overdose that the patient takes herself or himself.
“Nobody gets rich doing this,” Jonquiere said.
In Oregon, where doctor- assisted suicide has been legal since 1997, “aid in dying” isn’t a separate “billable” activity.
“We just always billed under the disease,” said Dr. David Grube, a now- retired family doctor who was among the first to prescribe a life- ending prescription under the Oregon law.
“So if a patient comes in with lung cancer, and wants aid in dying, and I counsel them about aid in dying, I put it under the diagnosis of their disease — lung cancer,” Grube said. He added that billings are modified for the time spent with patients.
You give an injection with a ... heavy sleeping drug, and you cause a really deep coma. Then you give a muscle relaxant — a snake poisonlike medication.
In Oregon, the three most common reasons behind requests for aid in dying, Grube said, are loss of control and autonomy, anhedonia ( meaning “absolutely nothing gives them joy or pleasure,” he said) and loss of dignity.
Words such as “dignity” and “suffering” are difficult to quantify, Grube said.
“But we cluster them into this concept of existential suffering,” he said.
“It’s not a pain scale, or the weight of the tumour, or where the tumour is. It’s about how you are responding to your problem.”
Still, many of those who request assisted death never go through with the act.
In the 18 years since Oregon’s Death With Dignity Act was passed, 1,327 terminally ill people had prescriptions written for lifeending drugs, and 859 patients died from ingesting the pills.